ملخص: background: Unintentional bronchial intubation may result in serious complications such as lung collapse or pneumothorax. these complications amount to sentinel events should be reported, and a hospital sentinel event policy should be implemented, including corrective actions to prevent recurrence. Methods: a 12-month prospective observational study in a multidisciplinary adult intensive care unit (iCU) to estimate the frequency of inadvertent bronchial intubation and its major sequels in intubated patients admitted to the unit. Complications will be reported as sentinel events attracting investigation by root cause analysis method, action plan, and follow-up. results: there were 36 (12.9%) cases of inadvertent bronchial intubations in 279 orally-intubated patients admitted to the iCU during the study period (1.5.2010 - 30.4.2011), 2 (0.7%) of them already developed total left lung collapse. the hospital sentinel event policy was activated followed by action plan, which included raising the awareness of the problem, presentations, and regular checking on the position of the tube following tracheal intubation at different location in the hospital.
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